Someone asked me what I thought about Donald Trump the other day. I was about to give a fairly obvious reply when the earnest tone and questioning look made me pause. As the penny dropped I realised I wasn’t being asked my opinion as a person, I was being asked what I thought as a psychologist. Did I think the US president was mentally unwell and thus not fit for the office he holds?

POTUS’ mental health has been attracting attention since the campaign. But it was after the US woke up to a Trump presidency on November 9th 2016 that things really got going. In a letter to President Obama in December (reported in the Huffington Post), three psychiatry professors asked for a ‘medical and neuropsychiatric’ evaluation of the then president-elect. This was followed by a welter of similar concerns including: a letter to the New York Times signed by 35 psychiatrists, psychologists and social workers; a petition on Change.org signed by more than 57,000 mental health professionals, and even a congressional proposal to have a White House psychiatrist.

The main diagnosis mentioned is ‘Narcissistic Personality Disorder’ from the DSM, the main manual of psychiatric classification in the US. You might be able to see why this has been a popular label. ‘Antagonism’, ‘grandiosity’, ‘attention seeking’, ‘impairments in empathy’ and a ‘sense of entitlement’ might be your conclusions too after a brief appraisal of the president’s Twitter feed. I appreciate how tempting it is to make such a diagnosis. It really may seem obvious. However, there are three areas where offering a clinical opinion, even of a controversial figure like Trump, gets sticky: ethics, accuracy, and the extent to which it is helpful. For anyone.

So is this armchair (or keyboard) diagnosis ethical? For psychiatrists in the US the official answer is ‘no’. Recently there has been much angsting about the so-called ‘Goldwater Rule’. This is the informal name for a section of the American Psychiatric Association’s ethical code, which precludes this kind of public pronouncement without direct knowledge of the case and without the consent of the person concerned. Appropriately enough this rule emerged from the 1964 Presidential campaign when US psychiatrists gave a similarly remote opinion on Republican presidential nominee Barry Goldwater. The authors of the letter to President Obama were clear that they were not actually diagnosing from a distance, but really this seems something of a fig leaf covering an ethically questionable stance as the hints they gave as to their opinion were heavy. The Goldwater Rule does not place any restriction on a psychiatrist expressing an opinion about particular politicians or policies. Neither does it stop them from discussing issues related to mental health more generally. However, there is big jump from that to speculating about formative experiences, subjective distress and other matters that you don’t have direct knowledge of.

And it’s not just explicit rules that come into play. While UK codes of conduct (e.g. from The Royal College of Psychiatrists, The British Psychological Society and the Health and Care Professions Council) don’t have a ‘Goldwater’ clause, they do contain references to respect, competence and the avoidance of harm to those who use health services. It’s hard to see how effectively weaponising your clinical opinion can be justified within these frameworks either, especially as the intention does actually seem to be to cause some kind of harm – to Trump’s career at the very least. It may be of course that these clinical opinions have been offered in a respectful and helpful spirit, in which case I stand corrected.

Some might of course answer to this ethical criticism by saying that the institutions and freedoms of the a country, the world even, are facing an existential threat. Screw the niceties! Some mental health professionals have asserted that it’s not only their right but their duty to call things as they see them at such a moment. When their country is threatened people have, after all, done a lot more than violate their professional codes. So, if the shoe fits…

Does it though? Are these clinical judgements accurate appraisals of the President’s functioning? Maybe, but a significant problem with mental health judgements is that they are somewhat subjective. One person’s depression may be another’s sadness, and professionals often don’t agree. Taking the DSM categories as an example, agreement between clinical practitioners after a clinical examination varies hugely according to the particular diagnosis being applied. While using highly structured assessment tools improves this somewhat, going the other way and relying on CNN, social media, and a good dose of partisan feeling, is not likely to produce the greatest reliability and accuracy. Dr Allen Frances, the editor of the fourth edition of the DSM, is one of the most prominent dissenters from public statements about Trump’s mental health. He suggested in his his own letter to the New York Times that efforts to diagnose the president were so poor as to amount to little more than ‘psychiatric name-calling’. Of course, as professionals we all may feel our own judgement is unlikely to be skewed by personal feeling, but this risk of bias is very good reason for observing the Goldwater clause. Just in case we’re wrong.

However, let’s say for a moment that we can get over any ethical scruples, put our prejudices to one side and make an accurate and reliable clinical diagnosis. Even from a distance. Let’s say, just for now, that we accept President Trump has a serious mental illness and we agree what that is. Where does that leave us? Well perhaps no more informed we were. Do the clinical opinions offered simply tell us any more than we already know? The President is antagonistic and attention seeking! I think many people may feel that they have worked that out.

An especially relevant issue with mental health diagnosis is that it may have very little to tell us about a person’s competence either. We’ve established that those doing the diagnosing may have no more data to draw on than the rest of us, but also the diagnosis doesn’t say anything about whether qualities such as antagonism or grandiosity make him bad at his job. Some of us may think they obviously do, but others might argue that some of his attributes are more common in authority figures than we might think. Perhaps they may even be necessary for some kinds of leadership? A diagnosis of Trump may be no more or less informative when it comes to competence than the mental health labels retrospectively applied to Churchill or Lincoln.

It’s also been pointed out by many people that, as well as being relatively uninformative, using diagnosis in this way is actually stigmatising for people who are struggling with mental health problems. Is this because they are being associated with Trump? Well that may be unpleasant for some, but a more important reason is that offering a mental health problem as a reason why a person cannot perform may leave someone who is struggling not to be defined by their diagnosis in an even tougher spot.

Of course what is being sought in all of this is a way of stopping someone because of serious concerns about his ability. Will someone step in and remove him please? In an ordinary job being judged as not up to it can be relatively straightforward. The person concerned might have a manager and an organisation may have policies around this kind of thing. The idea of such policies is usually, partly, to support employees to do better but also to protect the people they serve when they do not do their job adequately. What on earth do we do though if we think a head of a government isn’t up to it? Who judges someone with no superiors? Who guards the guards? It’s an age-old problem. ‘Performance issues in great ones must not unwatched go’ as Claudius might have said of Hamlet in a more PC version of medieval Denmark. Concerns over how to deal with kingly incompetence ran through the whole of Shakespeare’s history plays starting with the overthrow of Richard II. He was a poor king but was there a legitimate way to get rid of him? That question underlies the two parts of Henry IV and the dramas of the corrupted body politic that followed.

The Plantagenets largely solved capability worries via swords and bloodshed. These days we have elections. So, if a head of government has a boss it’s surely us. That is if we can agree sufficiently to replace one leader with another. The results of elections can be tough to swallow, though, when we can’t agree and our fellow citizens vote for the wrong person. If we can’t usefully pathologise our leaders we may have to turn our attention to our compatriots who messed it up. I mean Trump! Who on earth voted for him? They clearly need their heads examined!

Comments: 11

You recognise that he is your President, support him and wish the very best for the United States of America.
It doesn’t take someone that understands how minds work to understand that had Hillary or Bernie won, your country would be absolutely on its last legs. The left wing/Antifa etc are trying the hardest to make it that way – under the pay of Soros.
You’ll see, he’ll be remembered as one of the greatest presidents!!

Using a mental health diagnosis as a way of bringing somebody down is a terrible thing to do. The issue surely, is not whether the President has, could have a mental health diagnosis, but whether he is a good role model and has the right attributes to be President. Given what was revealed about a Trump prior to his election it is flabbergasting that he has risen to the highest office in the land. He admitted to being a sexual predator earlier in his life and this was borne out by video-recorded evidence. There are serious shortcomings within the system when such a man can still be President. Since his election, though, the Constitution has provided checks and balances whereby the world has been protected from some of his greater excesses. It will remain to be seen whether he us impeached or not, but for the meantime, he is the President that a majority of Americans have chosen. In a democracy, people get the leaders they deserve.

If we are serious about doing away with stigma and discrimination, it would be a good idea to have a President with a mental health diagnosis. The real issue is whether or not he/she is good at the job, not whether or not they have a diagnosis which is no more relevant than whether they have haemorrhoids or backache.

As for your question, ‘Who guards the guards’ – in a democracy we can only use the forces of democracy at our disposal, but it is a very salient question as to who can protect us from unscrupulous rulers while they bring about damage.

I think it is appropriate for critical mental health academics to formulate in context, as opposed to diagnose, clearly dangerous people such as Trump. Benny Goodman and I did so in the context of: Arendtian philosophical principles; globalisation and the rise of the alt right internationally; and the need for health academics to embrace a public/action intellectual critical standpoint: Goodman B, Grant A. 2017. The case of the Trump regime: The need for resistance in international nurse education. Nurse Education Today. 52: 53-56.

In this case formulation (certainly as many clinical psychologists might construe it) would be little different to diagnosis from an ethical standpoint Alec. Using clinical knowledge as a weapon intended to cause harm would be hard to justify under any established code of conduct for any discipline. Of course many may feel that is a breach that is amply justified by extreme circumstances. That still does not address the issues of bias in judgement. There are many other populist politicians I could formulate or diagnose on the basis of public utterances but others may legitimately disagree and point out my subjectivity. On the issue of competence my judgement is unlikely to be substantively different from someone else’s, clinical training or not. The answers to Trump are political not psychological and rest on those who oppose convincing others of the dangers. The only point I was making in this really was the inappropriateness of clinical tools for the job.

Okay John. We were coming at the issue in context, from an educational rather than clinical standpoint. We wanted to challenge the, in our view, general liberal-humanist caution against labelling, given the threats to healthcare/education of the Trump and equivalent regimes, with their alt right associations, across the word. I don’t see how political can be disaggregated rom other forms of principled response, educational or psychological, if you claim a critical standpoint position.

As I acknowledge there may be a case for people to get over their ethical scruples on an issue want may be perceived as a vital issue of conscience Alec. Though I’d argue that there is quite a bit of collateral damage associated with making that decision I can see how people get there. Aside from the direct issues around that though there are also the issues of the subjectivity of judgement. There are quite a few politicians (left and right though mainly of a populist stripe) I could offer a clinical judgement about. One persons mad may be another’s visionary. What I question above though is where these direct clinical judgement leave you. Really no further on. I did read you paper. I actually agree with much of it. Intellectual engagement and really full engagement? Bring it on. It’s a different thing from these very direct clinically informed attacks though and brings the discussion back into the area of a political debate rather than a (pseudo)clinical attack.

I guess we each have to work from where we’re culturally situated, John. I acknowledge what you say, and the good ethical grounds for restraint among clinicians and in clinical training. I’m more of a cultural outsider now, with diminishing institutional and professional allegiances – which is why I write what I write. Institutional and professional allegiances always pull people to the normative and militate against critical inquiry, which is why we need more critical mental health in my view. All the best John. Good blog!